Provider Demographics
NPI:1760994735
Name:SIMKOVICH, KYLE (ATC, FMSC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:SIMKOVICH
Suffix:
Gender:M
Credentials:ATC, FMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 MORADA PL
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603 MORADA PL
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3233
Practice Address - Country:US
Practice Address - Phone:626-319-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
CADC36697111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer